Helping patients with multiple chronic diseases manage their health is important. The RAND Corporation reviewed AHRQ’s 2014 Medical Expenditure Panel Survey data to estimate the prevalence and associated costs of managing patients with multiple chronic conditions. Patients with five or more chronic conditions account for 12% of the population, but 41% of the total expenditures. People with three or four chronic conditions account for 16% of the population, but 26% of total expenditures. People with one or two chronic conditions account for 31% of the population, but 23% of total expenditures. Patients with no chronic conditions account for 40% of the population, but only 10% of the total expenditures.
Public health leaders have been aware of the challenges around managing multiple chronic conditions for some time. Back in a 2004, ME Tinetti et al. described the challenges of prescribing medications for patients with different health priorities requiring advances in data collection, analysis and presentation. A year later, CM Boyd et al. suggested pay-for-performance programs based on existing clinical practice guidelines did not account for older patients with comorbidities and could lead to complicated pharmaceutical regimens with a high likelihood of an adverse drug reaction. In 2011, AK Parekh et al. published a relevant strategic framework, including goals to maximize proven self-care, address multiple chronic conditions in guidelines and facilitate research to fill knowledge gaps about, and interventions and systems to benefit, individuals with multiple chronic conditions. Subsequently, the National Quality Forum published a framework for measuring how well care was delivered to patients with multiple chronic conditions.
In the absence of high-quality evidence or recommendations from clinical specialty societies, how might one begin to consider addressing care among patients with multiple chronic conditions? Developing a mental model for every possible permutation of chronic disease would be daunting. Medicare’s own Chronic Conditions Data Warehouse is focused on only 27 common chronic conditions and 39 other chronic or potentially disabling conditions including mental health and substance abuse conditions. A 2009 study limited their analysis to a subset of six conditions (cancer, chronic kidney disease, heart failure, COPD, depression and diabetes) among Medicare beneficiaries with three conditions (heart failure, diabetes and chronic kidney disease) linked with the highest total Medicare payments.
Claims data can provide some insights into those chronic disease interactions that are associated with a disproportionate share of health care spend. P Lin et al. reviewed claims from over 135,000 privately insured US adults between 2014 and 2018 at Optum (disclaimer: I currently work for UnitedHealth Care, a subsidiary of UnitedHealth Group, a corporation that also includes Optum). The team used Piette and Kerr’s classification of chronic comorbid conditions as dominant (so complex or serious that they eclipse the management of other health conditions [e.g., class IV heart failure]), concordant (represent components of the same overall pathophysiologic risk profile and may be included in the same disease management plan [e.g., hypertension and diabetes]) or discordant (not related to the primary condition’s pathophysiology or treatment plan [e.g., diabetes and schizophrenia]). 17% of patients had no comorbidity and accounted for three percent of the cohort’s costs. Seven percent of patients only had a concordant comorbidity and accounted for another three percent of the cohort’s costs. 27% of patients only had a discordant comorbidity and accounted for 14% of the cohort’s costs. 24% of patients had both concordant and discordant comorbidities and they accounted for 27% of the cohort’s costs. The remaining 25% of patients with a dominant comorbidity accounted for 53% of the overall cohort costs. Having a dominant comorbidity appears to drive most of the dollar value of the claims in this group.
The Lin study doesn’t address the ability of the health care system to meaningfully intervene among patients who have discordant, concordant or dominant comorbidities to reduce healthcare spend. Our healthcare system would need a method to capture clinical conditions with relevant comorbidities including measures of disease severity, patient treatment preferences and some model for how to consider managing patients with different disease and comorbidity profiles. The inputs could be used in a meta-model to suggest treatment targets and prioritize suggested interventions to reduce the risk of complications that are most meaningful to the patient. Any comorbidity-focused approach would need to reviewed from a patient satisfaction and economic perspective before broad dissemination.
The most cost-effective method to address multiple chronic conditions is to delay their onset or prevent them altogether. The CDC’s National Center for Chronic Disease Prevention and Health Promotion is focused on behaviors to reduce the risk of developing chronic diseases. The Center focuses on tobacco use, poor nutrition, a lack of physical activity and excessive alcohol use. Unfortunately, most healthcare system incentives for providers, health systems and payers do not encourage prevention. From a patient and taxpayer perspective, developing interventions that encourage healthy behaviors may be more meaningful than any new health information technology platform or blockbuster drug.